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Health Affairs Editor-in-Chief Alan Weil interviews Sara Yeatman from the University of Colorado Denver to discuss her paper in the December 2022 issue assessing the effects of the 2009 Colorado's Family Planning Initiative on contraceptive access in college completion for women. They found the initiative led to an increase in college completion.
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;07 - 00;00;26;27
Alan Weil
Hello, and welcome to “A Health Podyssey”. I'm your host, Alan Weil. Access to effective and reliable contraception is a critical source of economic equality for women. Studies have shown that contraceptive access yields higher rates of school completion, participation in the labor force, higher incomes and lower poverty rates for women. But much of this evidence is 50 years old or more,
00;00;26;27 - 00;00;57;18
Alan Weil
dating back to the introduction of oral contraceptives. In 2009, Colorado implemented an ambitious program designed to increase access to contraception. The program coincided with renewed interest in LARCs, long-acting reversible contraception methods, notably IUDs and implants. The effect of contraceptive access on a key measure of economic opportunity, college completion, is the topic of today's episode of “A Health Podyssey”.
00;00;58;07 - 00;01;24;11
Alan Weil
I'm here with Sara Yeatman, professor in the Department of Health and Behavioral Sciences at the University of Colorado, Denver. Dr. Yeatman and coauthors published a paper in the December 2022 issue of Health Affairs assessing the effects of the 2009 Colorado family Planning Initiative on contraceptive access in college completion for women. They found the Colorado initiative led to an increase in college completion.
00;01;24;12 - 00;01;30;19
Alan Weil
We'll discuss these findings and more in today's episode. Dr. Yeatman, welcome to the program.
00;01;30;29 - 00;01;32;10
Sara Yeatman
Thank you. I'm delighted to be here.
00;01;32;22 - 00;01;52;05
Alan Weil
I'm happy to have you as a guest today to talk about this really interesting initiative. I remember when it occurred, it got quite a bit of attention, but that was some time ago. So maybe at the outset you could just describe to our listeners what was and is the Colorado Family Planning Initiative. Give us a little sense of why it was we're studying.
00;01;52;12 - 00;02;18;16
Sara Yeatman
Absolutely. Before I began, I'd like to acknowledge my coauthors Jim Flynn, Amanda Stevenson, Katie Genadek, Stephanie Mollborn and Jane Menken as well as our funders, the U.S. National Institute of Child Health and Human Development and the William and Flora Hewlett Foundation. I need to also acknowledge that my comments today are are my own and do not necessarily reflect the views of my funders or the U.S. Census Bureau.
00;02;18;18 - 00;02;44;00
Sara Yeatman
So the Colorado Family Planning Initiative, as you mentioned, it began in 2009 and it ran through 2014. Now, the goal of the program was to expand contraceptive access throughout the state. And the way in which it did that is, it was an influx of money, of a foundation, provided that funding ,$27 million that worked through the state's existing Title X clinics.
00;02;44;01 - 00;03;22;15
Sara Yeatman
So these are clinics that provide family planning and sexual health services throughout the state, particularly to individuals who don't have insurance or were underinsured, as well as to high numbers of adolescents for whom contraceptive access is often out of reach. Now, the main way that the initiative worked was by funding devices. Contraceptive devices can be very expensive, and particularly the most effective methods, those long-acting reversible contraceptives or LARCs, those include IUDs and implants, and they can cost upwards of $800.
00;03;22;23 - 00;03;48;20
Sara Yeatman
And so, frequently, clinics didn't have them available. Now, the CFPI, the Colorado Family Planning Initiative, made sure that those devices were available at every Title X clinic throughout the state. They also made sure that providers were trained in how to counsel clients on the full range of contraceptive devices, and knew how to insert these devices that maybe they weren't as familiar with previously.
00;03;48;29 - 00;03;52;14
Sara Yeatman
It also included some community outreach and advertising.
00;03;52;28 - 00;04;20;06
Alan Weil
So we often think of contraception as a thing that you can go to a clinic and get. And of course, the Affordable Care Act made contraceptive services free for those who have health insurance, so why is it important to have this? It sounds like this sort of layers on top of other policies to change the dynamics and the availability of particular contraceptives.
00;04;20;07 - 00;04;43;04
Sara Yeatman
Yeah. So it was started before the Affordable Care Act. And then also even with the ACA, not everybody has access to insurance or to high quality insurance. Additionally, you know, we can understand why adolescents might want to seek care outside of perhaps their parents’ insurance. And that is something that we know happens at Title X clinics.
00;04;43;10 - 00;05;00;10
Alan Weil
You have this current initiative that is designed to expand access. What do we know about how it changed use of contraception? And most important, I think for the purpose of your study, how it affected economic opportunity for women in Colorado.
00;05;00;18 - 00;05;33;23
Sara Yeatman
Other great research has demonstrated that CFPI increased use of contraception and particularly the share of methods that were IUDs or implants increased during the program. And that was particularly true for adolescents and for young adults for whom these methods were very rarely available previously. This other research has also demonstrated quite clearly that the adolescent birthrate fell under CFPI as well as the young adult.
00;05;33;23 - 00;05;37;07
Sara Yeatman
So those are 20 to 24 year olds. Their birth rate fell.
00;05;37;19 - 00;05;55;14
Alan Weil
So there's dramatic changes in use of contraception and birth rates. Again, that's not part of your study, but that we already knew were taking place. And then you add this dimension of looking at an economic outcome. Tell me a little more about what you are looking for and what you found.
00;05;55;19 - 00;06;20;01
Sara Yeatman
One of the motivations for federally funded family planning is this idea that not only does it change reproductive health outcomes, but it can also improve women's lives. But actually the evidence base for that is pretty thin, particularly when we think about the contemporary United States getting away from the introduction of the oral contraceptive pill in the 1960s. And so we wanted to test that.
00;06;20;01 - 00;06;51;05
Sara Yeatman
Does providing access to contraception improve women's educational outcomes? And in an earlier study, we were able to demonstrate that the CFPI increased women's high school completion. And so here we wanted to test--because I think the group of people whose high school completion is most likely to be impacted by expanded contraceptive use is a different group of people than the ones whose university completion is likely to be impacted by contraceptive use.
00;06;51;05 - 00;06;57;07
Sara Yeatman
I think those are different populations and so we wanted to assess whether indeed that was the case.
00;06;57;25 - 00;07;00;25
Alan Weil
And when you looked at college completion, what do you find?
00;07;01;01 - 00;07;27;05
Sara Yeatman
So we compare women in Colorado who were exposed to the program in high school ages to earlier groups of women in Colorado, as well as to comparison populations in other states. And what we find is that women who are exposed to the program, they had expanded contraceptive access in their high school years, their levels of college completion were 1.8 to 3.5 percentage points higher.
00;07;27;13 - 00;07;48;16
Sara Yeatman
Now, that range reflects different comparison groups that we were using, but it shows a pretty large increase in women's college completion because we're looking not just at women who use the program, but we're looking at what's called the intent to treat effect. So we're looking at that whole population exposed to the program. So everybody in the state of Colorado.
00;07;48;24 - 00;08;06;06
Alan Weil
So this seems like a really important point, that this is the effect across the population, even though not everyone took advantage of the program. And you mentioned the percentage point increase. Can you give me a sense of scale, what the numbers changed from to?
00;08;06;17 - 00;08;32;20
Sara Yeatman
So prior to CFPI, about 30% of women in Colorado had completed a four year degree by the ages 22 to 24, which is that age group we're looking at. And following CFPI, that number increased to about 34%. That change reflects some general increase that was happening anywhere and across the United States. But we're able to isolate that
00;08;32;20 - 00;09;01;14
Sara Yeatman
about 30% of women in Colorado between the ages of 22 and 24 were completing a four year college degree prior to the program. Now this increases to about 34% after the program, and we are able to identify that about two thirds of that increase is due to the Colorado Family Planning Initiative. So said another way, we think that there is a 6 to 12% increase in the rate of college completion in Colorado
00;09;01;14 - 00;09;02;27
Sara Yeatman
that's due to CFPI.
00;09;03;05 - 00;09;31;23
Alan Weil
Yeah, that's a really dramatic finding. I mean, not that the percentage points in of themselves aren't important, but what you're saying is something like a 10% gain. I realize there's variation, there's uncertainty in the estimate, but something like a 10% gain in the rate of college completion due to this intervention. That's a really phenomenally large effect for a single, as you said at the outset, not even $30 million program.
00;09;32;05 - 00;10;08;00
Alan Weil
I want to talk to you some more about what we do with this information. This is a very consequential finding. We'll put it in some policy context, think about where we might go with it. We'll have that conversation after we take a short break. And we're back, I'm speaking with Dr. Sara Yeatman about expanded contraception access in Colorado and its ties to college completion.
00;10;08;16 - 00;10;35;26
Alan Weil
Before the break, we heard that the CFPI, the Colorado Family Planning Initiative, according to this study, increased college completion rates by a few percentage points, about a 10% increase for women across the entire population. These kinds of changes in an important economic outcome are hard to come by, and so I want to spend some time talking about what we should do with these findings, what the implications are.
00;10;36;05 - 00;11;00;29
Alan Weil
Let's start, if we could, just about the general picture of economic empowerment and the role that college completion plays. Why it is important to study this. You noted the difference in target population for college completion and high school completion. So why is it important that we ask the question, what does access to contraception mean for the economic well-being of women?
00;11;00;29 - 00;11;27;20
Sara Yeatman
College completion remains incredibly important in the United States. It's important for accessing the middle class, and it's been linked to reduced morbidity. So illness, reduced mortality, death, and it's also been linked with increased lifetime earnings. So getting a college degree and getting it sort of early in one's life is incredibly important. And then showing that expanded access to contraception can improve women's college completion.
00;11;28;01 - 00;11;32;18
Sara Yeatman
It's showing that expanded access to contraception can improve women's lives.
00;11;32;27 - 00;12;03;10
Alan Weil
So part of what I'm interested in here is what seems like a very targeted initiative in one state showing these results. You mentioned it was foundation funded. It used sort of an existing infrastructure. Have you given some thought to what it would look like to try to achieve these kinds of results elsewhere? You mentioned that part of your study was about comparing the rates in Colorado to nine other states that have had sort of similar trends going in.
00;12;03;15 - 00;12;09;25
Alan Weil
What would it look like if we were to try to do this elsewhere? And is anyone trying that, to your knowledge?
00;12;09;25 - 00;12;29;02
Sara Yeatman
What would it look like to do this elsewhere? What a great and challenging question. I'm going to take your questions in reverse order. So at the state level, there haven't been-- well, there were two programs that were somewhat similar to CFPI. There was a program in Iowa in 2007, and there was a program in Delaware that began in 2015.
00;12;29;02 - 00;13;06;02
Sara Yeatman
But these are small, time limited programs at the state level like Colorado's. But at the same time, state legislatures are constantly having to approve funding for family planning. And so even though Title X is a national program, at the state level, state governments also provide essential family planning funding. And so there are some state legislatures that are trying to provide more funding for family planning, which often works through Title ten clinics, and thus could achieve things like what the Colorado Family Planning Initiative has achieved.
00;13;06;15 - 00;13;38;00
Sara Yeatman
At the same time, there are, as you might imagine, a number of state legislatures that are cutting that are restricting family planning funding. And so in those places, contraception is just getting harder and harder to obtain for for women, and particularly for young women. So we're seeing sort of divergent trends with state level funding. Now, if we think about national funding, Title ten is the only dedicated family planning funding stream at the national level, and it's been around since 1970.
00;13;38;00 - 00;14;12;15
Sara Yeatman
It was first introduced by President Nixon, and it's long received bipartisan support. But it's also been underfunded for a very long time. That federal level of funding has become, even though it was long bipartisan, has lately become hotly contested. And so it was really restricted in 2019. And lots of states pulled out of the program, which we can imagine would have a big impact on contraceptive access and then women's education, as we've, you know, shown in Colorado.
00;14;13;10 - 00;14;45;14
Sara Yeatman
But that has been--that sort of 2019 restrictions were turned around in 2021. At present, there is a bill before the Senate called the Expanding Access to Family Planning Act, and that act proposes to increase and stabilize funding for Title X. And I think those are both important pieces, being able to have a reliable amount of funding that goes to these Title X clinics throughout the country that can provide essential family planning and sexual health services is really important.
00;14;45;28 - 00;14;57;18
Sara Yeatman
And two of those senators that are co-sponsoring that bill are Colorado senators. And I think their enthusiasm for it comes in no small part because of what they've seen happen in Colorado with the Colorado Family Planning Initiative.
00;14;58;00 - 00;15;27;08
Alan Weil
So you were very measured in your words, but maybe I'm going to be a little bit more direct and just say it sounds to me what you're describing is that even as the political discourse often focuses on abortion as a dividing line, it sounds like contraception as a whole is also caught up in that same dividing line in the country, that there are states that are not just restricting access to abortion, but they're also restricting access to contraception.
00;15;27;08 - 00;15;58;05
Alan Weil
I you didn't say it, but I'm going to gather when you described the divisions that those visions are similar states that are doing activities in both of those areas. And so this this program is getting caught up in the politics of reproductive health and women's health far beyond abortion and having consequences for access to contraception as well. I really don't want to put words in your mouth.
00;15;58;05 - 00;16;09;24
Alan Weil
I said a lot right there. But I am curious, given your expertise, whether I've captured the picture accurately or if you would modify what I said to make it more accurate?
00;16;10;05 - 00;16;44;26
Sara Yeatman
I think that's exactly right. And it's happening in two ways. One, by targeting abortion, you know, abortion clinics are closing and abortion clinics are often main providers of family planning care, particularly in rural areas, particularly in areas where there are few other options. And then the second way, I think with the recent Supreme Court decision with Dobbs and the overturning of Roe v Wade, politicians at the state level and at the national level have become empowered, newly empowered, and are not just attacking abortion, but are actually directly attacking contraceptive access as well.
00;16;45;04 - 00;16;56;22
Sara Yeatman
And we're seeing that in bills going before state legislatures trying to reduce funding for family planning, and that will have consequences, and in those states.
00;16;57;12 - 00;17;30;29
Alan Weil
So at the outset, we discussed a number or I mentioned a number of consequences that have been tied to access to contraception over, as we've mentioned, many decades of evidence around labor force participation, around incomes and poverty. These are all, of course, economic outcomes. You mentioned the tie between the economic outcomes and the health outcomes. Does having a stronger evidence base around these economic and health benefits change the discussion?
00;17;31;03 - 00;17;47;14
Alan Weil
Do you feel like there is room to talk about family planning as an opportunity for improvement that pulls it away from some of these social issues? Or are we just sort of stuck in in the place where we are now?
00;17;47;26 - 00;18;15;18
Sara Yeatman
I think there are a lot of motivations for why we should provide good contraceptive access to everybody in the United States. I mean, I think there's a human rights argument to it. There's a justice argument. But the fact that access to contraception can also support women in achieving their economic goals, their educational goals is another important piece of the puzzle.
00;18;15;23 - 00;18;32;28
Sara Yeatman
And I think when it comes to motivations for politicians to fund programs, this is an important piece of additional evidence that in providing access to contraception, women are more likely to complete college.
00;18;33;12 - 00;18;47;07
Alan Weil
Well, Dr. Yeatman, I thank you for doing the research that led to these findings and for explaining it and putting it in context, which I think is so important, particularly for work like this. Thank you for being my guest today on “A Health Podyssey”.
00;18;47;13 - 00;18;51;00
Sara Yeatman
Thank you for having me. It was a lot of fun.